Provider Demographics
NPI:1679643753
Name:MVP PHARMACY LLC
Entity Type:Organization
Organization Name:MVP PHARMACY LLC
Other - Org Name:MOUNTAIN VIEW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:HORROCKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-808-1546
Mailing Address - Street 1:425 MEDICAL DR
Mailing Address - Street 2:STE 100
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4945
Mailing Address - Country:US
Mailing Address - Phone:801-295-3439
Mailing Address - Fax:801-299-1696
Practice Address - Street 1:425 MEDICAL DR
Practice Address - Street 2:STE 100
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4945
Practice Address - Country:US
Practice Address - Phone:801-295-3439
Practice Address - Fax:801-299-1696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9719138-1703333600000X
3336C0003X, 3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1679643753Medicaid
2159080OtherPK